ECHOCARDIOGRAPHY IN INTERVENTIONS

Echocardiography during

Mitral Valve

Percutaneous Interventions Dr.Praveen Nagula

Introduction

• TEE is routinely used to guide Percutaneous interventions involving

the Mitral valve.

MC percutaneous procedures are

• 1.PBMV (Percutaneous Balloon Mitral Valvuloplasty) for Rheumatic

Mitral stenosis.

• 2.Edge to edge repair with the Mitra clip for MR.

• 3.Closure of Prosthetic ParaValvular Mitral Leakages (PVML).

• 4.TAMI

PBMV

• Commissural fusion is the requisite lesion for PBMV to be effective.

• Not effective for degenerative calcific MS, where mitral annular

calcification is the main lesion.

Preprocedural assessment

• Assessment of valve area

• The mean doppler gradients

• Pulmonary artery pressure.

• 2Dplanimetry - PSxA where the maximal diastolic orifice present.

• Entire MV orifice should be seen.

• Avoid high gain settings – underestimation of MVA

• Correlates with anatomic valve area as assessed on explanted valves.

• Planimetry by 3D echo is more accurate and reproducible than 2D

echocardiography.

• Mitral maximal and mean doppler gradients are also calculated.

• Maximal gradient, derived from peak mitral velocity, is influenced

by LA compliance and LV diastolic function.

• Mean MV gradient more accurately reflects the MS severity.

• CW doppler measurements across MV have good correlation with

invasive measurements using Transspetal catheterization.

• Highly rate and flow dependent, as gradient is a function of the

square of the transvalvular flow.

• HR and CO significantly affect the transmitral diastolic gradient.

Assessment of valve anatomy and suitability

for PBMV

1.Wilkins score

• 2D echo valve assess morphologic leaflet mobility , flexibility,

thickness, calcification, subvalvular fusion,commissural fusion,

calcification.

• A score greater than 8 suggests the valve may not be suitable for

PBMV.

2.Assessment of commissural calcium - each half commissure with

detection of high intensity bright echoes score of 1.

• Significant predictor of achieving an MVA post PBMV greater than

1.5cm² without creating significant MR.

• Does not add predictive value to score more than 8 in Wilkins score.

• Commissural calcification grade0/1 had large valve areas and better

improvement of symptoms than patients with grade 2/3.

3.Echocardiographic grouping - based on the echocardiographic and

fluoroscopic calcification assessment of the following characteristics:

valve mobility,

fusion of the subvalvular apparatus,and

the amount of leaflet calcification.

4.Real time 3D echocardiographic score - evaluates both mitral

leaflets and sub valvular apparatus.

• Highly reproducible with good interobserver and intraobserver

agreement in the assessment of MV morphology in patients with

MS.

• Superior for detection of calcification and commissural splitting.

• High calcification RT TT3DE –post procedural MR.

• No scoring system has been proved to be superior.

• They should be used in conjunction with one another as part of a

comprehensive echocardiogrpahic assessment of the valve

pathology.

C/I to PBMV

• MVA >1.5 cm²

• LA thrombus

• More than mild MR

• Severe or bicommissural calcification

• Absence of commissural fusion

• Severe concomitant aortic valve disease or severe combined TS and

TR.

• Concomitant CAD requiring CABG

Intraprocedural guidance

• Single balloon (Lock and colleagues)

• Double balloon (Al Zaibag and colleagues)

• Inoue balloon (MC used)

• Low intraprocedurral and periprocedural mortality and a success rate

of 95% or more.

• MVA increases to 1.9-2.0 cm² and NYHA function improves to class

I-II in 90% of cases.

• TEE should be done to exclude an LA thrombus and to reassess

contraindications to PBMV.

• LA thrombus – postpone (can be attempted in certain situations)

• Nonresolving thrombus – Surgery > PBMV

• Preferred Transeptal puncture site is in the posterior, a more

inferior region of the fossa ovalis.

• TEE or Intracardiac echo guidance is helpful, especially in

Pts with dilated atria or unusual morphology of the interatrial septum

(IAS) such as large atrial septal aneurysm, prior IAS surgery, or

distortion of the IAS from the scoliosis or prior pneumectomy.

• Tip of the needle for TS puncture can be identified by a tent like

indentation of the IAS on TEE.

• Height above the valve is best appreciated in the 4chamber view (0),

AP orientation is obtained using a short axis view at the base(30-45),

superior inferior orientation is seen on long axis view (90-100)

• X plane shows simultaneous AP,SI orientations.

• Inflation of the balloon in the subvalvular region should be avoided,

as this may lead to valvular, chordal or papillary muscle rupture.

• Hemodynamic deterioration during balloon inflation.

• Close monitoring of hemodynamic parameters is mandatory during

balloon inflation.

• Dilation of the MV Orifice due to splitting of the commissures in

evident by echo and fluoroscopy – the constriction of the balloon,

visible at its waist at the level of the mitral leaflets, suddenly

disappears.

Post procedure

• Severity and location of MR (newly developed MR emerging from the

commissures indicate a rupture of the valve lealflets (1.4-9.4%

develop significant MR)

• Mitral valve leaflet mobility

• Post PBMV MVA using mean doppler gradients,2D,3D MV

planimetry.

• Commissural opening

• Pericardial effusion

• L-R shunt through ASD secondary to TS puncture.

Why not PHT ?

Atrial compliance

A newly created ASD

Changes in hemodynamics

Successful PBMV

• As an MVA 1.5 cm² or more

• MR 2+

• Absence of complications

MITRAL REGURGITATION

Edge to Edge repair with the Mitraclip for

Mitral Regurgitation

• Alfieri – surgical technique of suturing the free edges of the mid

portions of the Anterior(A2) and Posterior (P2) mitral valve scallops

to create a double mitral valve orifice to treat MR.

• St Goar developed the Mitra Clip as a catheter based approach to

create a double MV orifice and thereby reduce MR.

Mitraclip system

• Only percutaneous method available to alter the mitral valve

morphology and annulus diameter and reduce MR.

• Transeptal approach

• 2 arms that form a clip when closed.

• Clip arms are opened in LV – during a pullback into LA, the central

portions of AML,PML are entrapped.

• Double orifice reduces MR.

Echocardiographic parameters essential for evaluation

before, during and after Mitraclip implantation

• Quantification of mitral valve morphology and MR severity.

• Guidance of the MitraClip system during the procedure.

• Assessing the intraprocedural results.

• Identification of complications during the procedure.

• Assessment of final results post Clip implantation in regard to MR

severity and diastolic gradient.

• Follow up regarding MR severity, residual shunting through the atrial

septum at the site of transseptal puncture, and pulmonary artery

systolic pressure.

Patient selection

• Impaired LV function

• LVEF <40%

• Mitraclip implantation can be safely performed with good results even

in patients with LVEF <20% - Franzen and colleagues.

• Moderate to severe MR (>3+ to 4+).

Morphological characterization for

Mitraclip eligibility

EVEREST criteria

• Coaptation length of 2mm

• Depth of <11mm

• Flail gap <10 mm

• Flail width < 15 mm

Imaging of Mitral valve

TEE – valve morphology

• 0 – (upper esophagus) A1 and P1 segments,A2 and P2 –

midesophagus,A3 and P3 distal esophagus.

• 60 – intercommissural views – P1,A2,P3 –along the plane.

• Clockwise rotation – A1-A3 are seen

• Counterclockwise – P1-P3 are seen

• LVOT view – A2 and P2 segment

• Transgastric short axis views – all segments of both leaflets.

• X plane imaging – valve segments and commissures

• Enface views of the mitral valve -3D echo

• Submitral apparatus view from LV

• Posterior leaflet prolapses are best visualized from the LA view

• Anterior leaflet is well seen from the LV.

• Anterior prolapse assessment is more difficult.(scallops are less

pronounced)

• More accurate than the 2D echo.

• High temporal and spatial resolution

Guiding of the Mitraclip procedure

• 3D TEE > 2D TEE – regarding position of the

catheters,wires,devices,target structures in a single view.

• TS puncture

• Steering of the delivery catheter

• Proper mitraclip procedure perpendicular to the line of coaptation in

the middle segments of the mitral valve.

• 30% reduction in the procedural time compared with 2DTEE and

fluoroscopy.

Mitraclip procedure

Additional Mitraclip implantation

• Fluoroscopy is helpful in positioning of a second mitral

clip,as it should be alligned as parallel as possible to fisrt

clip.

• Entrapment between 2 mitraclips to be avoided –

uncorrectable residual MR.

Assessment of complications

Paravalvular Mitral Leaks• Frequent causes for reoperation.

• Dehisced suture or a complication of infective endocarditis.

• 60% occur in the first year after surgery.

• Subsequent risk decreasing to between 0.06 %- 5.4%

• Isolated or multiple

• Assosciated with any valve types

• Small and asymptomatic

• Spontaneous closure by fibrosis of the valve annulus.

• Clinically significant 1-5%

• PVML most frequently in the mitral commissural areas (76%)

• 3D TEE is optimal

• First successfully performed PPVL closure was reoprted in 1992 by

Hourhain and colleagues.

• Double umbrella Rashkind occluder device in 7 patients.

PVMC

• Assessment

• Intraprocedural guidance

• Post procedural assessment

Prosthetic valve evaluation

Stress echocardiography

Latest …

Endovalve Herrmann

Mini thoracotomy

No need of extracorpreal circulation

Bovine Pericardium

Lutter valve

Transapical appproach

Self expanding nitinol stent

Cardia AQ valve

Porcine pericardium

Nitinol self expanding stent\

Transseptal appraoch

First percutaaneous valve to be

implanted in native valve

Bovine pericardium

Tiara valve

Self expanding stent

D shaped atrial portion

Ventricular portion outer coating to avoid

leaks

3 anchors

Successful implantation rate -81%

TIARA

• Transcatheter Apical Mitral valve Replacement

TAMI

• C:\Users\LAPTOP\Documents\TAMI of the Tiara_

FIM Study of a Mitral Bioprosthesis_(360p).mp4